A review on interventions to reduce medication discrepancies or errors in primary or ambulatory care setting during care transition from hospital to primary care.

INTRODUCTION: Transition of care from hospital to primary care has been associated with increased medication errors. This review article aims to examine the existing evidence on interventions to reduce medication discrepancies or errors in primary or ambulatory care setting during care transition from hospital to primary care.
METHODS: We systematically reviewed the articles in primary or ambulatory care setting on patients with care transition that involved medication safety, discrepancy, or error as outcome assessment. Primary research articles were selected. Interventions in nursing homes or long-term care facilities were excluded from the review.
RESULTS: We found 6 articles that met the inclusion criteria and 4 are prospective cohort study. The key players were pharmacists, nurse, and primary care physician. The interventions included care communication, medication reconciliation or review, and clarifying medication-related problems.
CONCLUSION: There is evidence that interventions in primary care setting reduce medication discrepancies on patients with the transition of care from hospital to primary care setting. Only one randomized trial involving pharmacist-led medication reconciliation was done in an outpatient setting. More good-quality randomized controlled trials should be carried out to confirm the evidence.

Introduction

Transition of care refers to the movement of patients between health-care practitioners, settings and home as their conditions and care needs change.[1] During these transitions, medication changes, complex medication regimens, and incomplete handoff of information between caregivers and health-care professionals involved in patient's care contributes to potential risk factors for medication discrepancies.[2]

Transition of care from hospital to primary care has been associated with increased medication errors, with an estimate of 60% of medication errors occurring during times of transition.[3] The impact of the errors encompasses patient safety, adverse drug reaction, harm, and cost of unplanned hospitalization.[4] The risk of medication errors increases with the number of medications, duration of admission, age of patients, female gender, comorbidities, use of high-risk medications, history of drug allergies, patient compliance issues, and poor renal or liver function.[5]

Medication discrepancies are defined as inconsistencies between two or more medication lists.[6] Medication discrepancies can be classified as intentional, where changes to medications are made by prescribers based on patient's medical condition, or unintentional, where changes are made without being aware of patient's self-reported intake of medications and medication history. Among the hospitalized elderly in a local study, the authors found that 23.3% had at least one actual unintentional medication discrepancy on discharge.[6]

Various interventions have been investigated to reduce the medication error or discrepancies during transition of care from one health-care institution to another. Intervention in the inpatient setting has been well investigated with electronic medication reconciliation, structured communication, and multidisciplinary team interventions were shown to be helpful in reducing errors.[78] However, there is relatively sparse evidence on intervention in the primary care. This review article aims to examine the existing evidence on interventions to reduce medication discrepancies or errors in primary or ambulatory care setting during care transition from hospital to primary care.

Methods

A PubMed and Embase search was done in January 2017 to identify suitable articles published from January 1, 1980 to December 31, 2016. The literature search strategy used was “[transition of care] AND ([medication safety] OR [medication discrepanc*] OR [medication erro*]) AND ([ambulatory care] OR [primary care]).” Primary research articles in primary or ambulatory care setting on patients with care transition were included for review. Figure 1 illustrated the process of study selection in a flowchart.

Figure 1

Flowchart describing the process of study selection

Articles with medication safety, discrepancy, or error as outcome assessment were selected. Hand searches through reference lists of key articles were also undertaken. Full text from those abstracts that were considered relevant was assessed independently by two reviewers for their suitability for inclusion and any differences between the two reviewers were resolved by discussion with a third reviewer. Articles that involved interventions used in the nursing home or long-term care facilities were excluded.

Grading of level of evidence and strength of recommendation was done for the selected articles based on strength of recommendation taxonomy (SORT).[9] Levels of evidence from 1 to 3 for individual studies are used in SORT, where level 1 refers to good quality patient-oriented evidence; level 2 refers to limited quality patient-orientated evidence; and level 3 refers to other evidence such as consensus guidelines, extrapolations from bench research, usual practice, opinion, disease-oriented evidence (intermediate or physiologic outcomes only), or case series for studies of diagnosis, treatment, prevention, or screening.[9] The study characteristics and level of evidence of the included studies are shown in Table 1.

Table 1

Study characteristics and the level of evidence by SORT[9]

Results

Search and study characteristics

A total of 300 titles were identified at the initial electronic search, which subsequently yielded 23 potentially relevant articles after screening the titles and abstracts. Further assessment of the full text of these studies and hand searches led to a total of six primary research articles that fit the inclusion criteria for the review. Seventeen articles were excluded after screening the full text. Figure 1 described the steps involved in the search and selection process.

Table 1 outlined the key characteristics of the individual studies. This includes the first author, year the study was published, type of study, location of the study conducted, and level of evidence by SORT.[9]

Study validity

There was no published high-quality randomized controlled trial in primary care setting looking at the outcome of reducing medication errors or discrepancies for patients with care transition. Most of the studies included in this review are prospective cohort studies [Table 1]. The baseline characteristics and inclusion of all studies were clearly described. Exclusion criterion was not stated in one of the studies.[10] The sample size calculation was clearly described only in one of the studies.[10] Most of the studies are level 2 evidence by SORT.

Table 2 summarized the inclusion and exclusion criteria of the included studies. Three studies included patients aged 50 years or older and another three included all patients aged 18 years or older. Number of medications was considered as an inclusion criterion for 2 studies. The diagnosis on discharge was considered as an inclusion criterion for 3 studies. Patients who were unable to speak or understand English were excluded in 4 studies. The other details of the exclusion criteria were shown in Table 2.

Table 2

The inclusion and exclusion criteria of the included studies

Intervention

The key player for the intervention is mainly the pharmacist who provides phone interview follow-up,[10] home visit,[11] or clinic-based consultation service.[1213] There is only one study where primary care physician contacted the patient for intervention.[14] The consideration for patient selection included number of medication, age, and selected chronic disease diagnoses. The details of the interventions included care communication, medication reconciliation or review, and clarifying medication-related problems. These interventions were done through phone interviews, home visits, and face-to-face consultations in the clinic [Table 3].

Table 3

The characteristics of the interventions of the included studies

Study result

There was increased medication discrepancies identification or resolution in all the studies included in this review despite that the key player of the interventions was different. The presence of medication discrepancies among patients discharged from the hospital can be alarming, with studies showing 81%–94% of the patients in the intervention arm had at least one identified medication discrepancy.[1315] The factors or types of discrepancies were stated in 3 studies, where patient-level factors were the most common for 2 studies[1314] and system level factor was the most common for another study.[15] The details of the results of the included studies are summarized in Table 4.

Table 4

The result details of the included studies

This review focused on intervention with aims of improving medication safety or reducing medication discrepancies or errors, hence the outcomes are not heterogeneous. However, one study also looked at the outcome on rehospitalization and emergency department visit, which showed a significant reduction in the composite end point.[12]

Discussion

Key player and method of intervention

This review indicated that considerable work can be executed by different health-care professional in primary care setting to reduce medication errors or discrepancies on patients with transition of care from hospital to primary care setting. The key player is the pharmacist, who ensures the best medication list, clarifies the medication problems and gives recommendation to the primary care physician. Different methods of execution, namely face-to-face, through phone, or home visit, were associated with favorable outcomes. The role of community pharmacists in both inpatient and outpatient settings were reported in the literature.[16] The interventions by community pharmacists were found to improve drug-related problems after discharge. The influential elements of the intervention were found to be completeness, accuracy, and clarity in information exchange, coordination of care which involved quality assessment, planning, and organization, communication in terms of personal and direct contact, accessibility and timeliness.[16]

Timing of intervention

The time of contact for the intervention ranged from within 24 h of discharge to the first visit of primary care physician in this review. Doing face-to-face interview in a separate appointment between the discharge and physician visit was found to be a challenge, with possible reasons of cost barrier, transportation barrier, or with overlapping home health service. This was resolved by conducting the medication reconciliation interview immediately before the physician follow-up appointment.[13] In a study examining frequency and patterns of rehospitalization, 19.6% of the 11,855,702 Medicare beneficiaries who had been discharged from a hospital were rehospitalized within 30 days, and 34% were rehospitalized within 90 days.[17] Thus, it is important to identify the ideal timing for intervention to reduce rehospitalization related to medication errors or discrepancies.

Causes of medication discrepancies

The causes of discrepancies identified can be at either the system[15] or patient level.[1314] A different approach may be required to target different causes of discrepancies. A rule-based automated medication reconciliation algorithm had been experimented during care transitions to complement human medication reconciliation, especially in time-critical scenarios.[18] However, patient-level discrepancies might not be detected.

Medication reconciliation

The details of the interventions in this review included care communication, medication reconciliation or review, and clarifying medication-related problems. Medication reconciliation has been identified by the Ministry of Health's National Medication Safety Committee as one of the medication safety priorities.[19] In Singapore, care coordinators under Aged Care Transition (ACTION) initiative provided transitional care to high-risk patients to reduce unnecessary readmission to acute hospitals. Through a program named pharmacist-outreach programme (POP), ACTION team and hospital pharmacist carried out medication management at home. Through this project, 75% of patients who were referred to POP had their drug-related problems resolved and at least 90% of them felt that they could better manage their medications after the program.[20]

Randomized controlled trials had been carried out in the hospital setting on medication reconciliation practices. In a meta-analysis, pharmacy-led medication reconciliation interventions were found to be an effective strategy to reduce medication discrepancies and had a greater impact when conducted at either admission or discharge but were less effective during multiple transitions in care.[7] However, this review is targeted at reduction of medication errors or discrepancies as outcome focusing on primary care as the site of intervention. There were interventions in the primary care setting, looking at outcomes of fall reduction of elderly, preventable drug-related morbidity, and hospital admission. However, the meta-analysis of these randomized controlled trials failed to demonstrate significant outcomes.[21] No studies with a higher SORT grading was found in the primary care setting.

Limitations

The search strategy of this review included two key databases and was supplemented by reviewing the references of the relevant studies. As the targeted outcome of this review was limited to medication errors, safety or reconciliation, clinical trials with better methodology looking at clinical outcomes of rehospitalization, improved laboratory parameters, and falls reduction were not included. We recognize that there are other prognostic factors or events which potentially influence the stated clinical outcomes.

While this review has showed a high number of medication discrepancies, there is limited evidence for pharmacist-led medication reconciliation to reduce the medication discrepancies. We only found one randomized trial involving pharmacist-led medication reconciliation done in an outpatient setting which showed 50% resolution of medication discrepancies.[12] Pharmacist-led medication reconciliation may reduce medication discrepancies but more studies need to confirm this finding.

Conclusion

There is evidence that interventions in primary care setting reduce medication discrepancies for patients with transition of care from the hospital to primary care setting. Only one randomized trial involving pharmacist-led medication reconciliation was done in an outpatient setting. More good-quality randomized controlled trials should be carried out to confirm the evidence.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.